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The Use of Media as a Sleep Aid in Adults
Article in Behavioral Sleep Medicine · October 2014
DOI: 10.1080/15402002.2014.963582 · Source: PubMed
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This article is a post-print version.
Publisher version available at http://www.tandfonline.com/doi/abs/10.1080/15402002.2014.963582
The Use of Media as a Sleep Aid in Adults
Liese Exelmans | liese.exelmans@soc.kuleuven.be
Jan Van den Bulck | jan.vandenbulck@soc.kuleuven.be
School for Mass Communication Research, KU Leuven, Belgium
Article accepted for publication in Behavioral Sleep Medicine
Please cite as:
Exelmans, L., & Van den Bulck, J. (2014). The Use of Media as a Sleep Aid in Adults. Behavioral
Sleep Medicine, (ahead-of-print), 1-13.
Corresponding author: Liese Exelmans, School for Mass Communication Research, Parkstraat 45,
3000 Leuven, Belgium. E-mail: liese.exelmans@soc.kuleuven.be Telephone: 003216323231
1
The Use of Media as a Sleep Aid in Adults
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Abstract
A sample of 844 adults, aged 18-94 years old, was queried about media habits and sleep behavior in
face-to-face interviews with standardized questionnaires. A substantial proportion of this sample
reported using books (39.8%), television (31.2%), music (26.0%), internet (23.2%) and videogames
(10.3%) as a sleep aid. The use of media as sleep aids was associated with increased fatigue and higher
scores on the Pittsburgh Sleep Quality Index (PSQI), indicating poorer sleep quality. There was no
relationship with sleep duration. Finally, results suggest that media use coincides with later bedtimes,
but also later rise times, a process called time shifting.
The Use of Media as a Sleep Aid in Adults
3
The Use of Media as a Sleep Aid in Adults
In comparison with 50 years ago, self-reported sleep duration has declined by approximately
1.5 hours (Kronholm et al., 2008; Van Cauter, Spiegel, Tasali, & Leproult, 2008). Prior literature has
linked media use with sleep displacement, whereby media use in the evening is associated with later
bedtimes and thus shortened sleep duration (Adam, Snell, & Pendry, 2007; Cain & Gradisar, 2010; Van
den Bulck, 2004). The majority of research on sleep displacement by media has been conducted on
children and adolescents. For instance, previous studies on the impact of electronic media on sleep in
children and adolescents concluded that the use of television, computers, games, internet, mobile
phones, and music was consistently related to delayed bedtime, shorter sleep duration (Cain & Gradisar,
2010) and longer sleep latency (Higuchi, Motohashi, Liu, & Maeda, 2005; Shochat, Flint-Bretler, &
Tzischinsky, 2010).
Surprisingly, much less is known about the possible effects of the media on adults’ sleep. The
impact of media use on sleep has nonetheless been shown to have long term effects: Johnson and
colleagues (2004) found that excessive television viewing during adolescence (> 3 hours a day) was
significantly related to a higher risk of frequent sleep problems in early adulthood. Moreover, a
reduction in the time spent watching television to less than 1 hour a day was associated with a
significantly lower risk of sleep problems in early adulthood. In adults, however, Custers & Van den
Bulck (2012) found that neither the availability nor the use of the internet or television in the bedroom
predicted reduced sleep quantity or increased tiredness. Their results suggested a process of time shifting
(where media use coincides with a delay in bedtime, but also a delay in rise time) rather than time
displacement (where time spent on a certain activity such as watching television replaces time that
would otherwise be spent on sleep). When time shifting occurs rather than time displacement, there is
no effect on total sleep duration by heavy media use (Van den Bulck, 1999).
In contrast with the majority of research focusing on negative relationships between media use
and sleep quality, some researchers have examined the media as sleep facilitators (Eggermont & Van
den Bulck, 2006; Gooneratne et al., 2011). For example, Gooneratne et al. (2011) found that television
was the most commonly used method to treat sleep problems in a sample of adults aged 65 years and
The Use of Media as a Sleep Aid in Adults
4
older. However, it has been argued that the use of media as a sleep aid might disturb rather than facilitate
sleep (Bloom et al., 2009; Eggermont & Van den Bulck, 2006). Eggermont & Van den Bulck (2006)
investigated this hypothesis in a sample of 2546 adolescents. More than one in three adolescents
reported using television to help them fall asleep and more than one in five indicated using computer
games as a sleep aid. Contrary to what might be expected, the results of the study suggested that while
adolescents indicated using the media as a sleep aid, such behavior was associated with later bedtimes
on weekdays, a reduction in sleep duration and higher levels of self-reported tiredness.
The present study builds on the work of Eggermont & Van den Bulck (2006) and aims to extend
the literature by studying the relationship between use of media as a sleep aid and sleep quality in a
sample of Flemish adults. We therefore formulated the following four research questions: 1) To what
extent are the media being used as a sleep aid in adults? 2) Do adults who indicate using the media as a
sleep aid report a better sleep quality? 3) How is the use of media as a sleep aid related to bedtime, sleep
duration and tiredness? and 4) Is the use of media as a sleep aid related to age, gender or education?
Method
Design
A sample of 844 adults in Flanders, Belgium was queried about media habits and sleep behaviors. A
two-step sampling method was used. First, 44 cities or villages in Flanders, Belgium were randomly
selected. Next, 20 addresses were selected from the telephone directory of each city or village following
a random selection protocol. Data were gathered by means of face-to-face interviews using standardized
questionnaires. The interviews were conducted by forty-four undergraduate students who had received
extensive interviewer training (Carton & Loosveldt, 1991). The effects of this training on the quality of
responses has been demonstrated by Loosveldt & Billiet (1988). Interviewers were instructed to go to
the addresses in the order in which they had been selected and to proceed to the first building to the left
of the building on the address list. They had to interview the adult (≥18 years old) member of the
household who was the first in line to celebrate his or her birthday to avoid limiting the sample to those
at home and/or most likely to open the door (Oldendick & Link, 1994). When no one answered or when
The Use of Media as a Sleep Aid in Adults
5
the person selected was not at home, they had to try to initiate contact three times before moving on to
a replacement address, to reduce undersampling of those with an active lifestyle. The process stopped
when the interviewer had conducted 20 successful interviews. Respondents were guaranteed that all
answers would be treated anonymously. The study received ethical clearance at Faculty of Social
Sciences of the KU Leuven and informed consent was obtained from all respondents.
Measures
Media use as a sleep aid. Following Eggermont & Van den Bulck (2006), we measured media
use as a sleep aid by asking respondents how often they used television, video games, music, books and
the internet to help them fall asleep. Response categories were never (1), rarely (2), sometimes (3), often
(4). For logistic analyses, this variable was dichotomized (0 = never used television, video games,
music, books or the internet as a sleep aid and 1 = used them at least occasionally). For analyses of
variance, the “sometimes” and “often” categories were merged: the highest score in these analyses thus
reflects all respondents who indicated using a media channel sometimes or often.
Sleep Hygiene. The Sleep Hygiene Index (Mastin, Bryson, & Corwyn, 2006) is a 13- item selfadministered index that measures the frequency of engagement in behaviors purported to impact sleep
hygiene. Response categories were always (5), frequently (4), sometimes (3), rarely (2) and never (1).
Items are summed in order to yield a global assessment of sleep hygiene. A higher score is indicative
of a more maladaptive sleep hygiene (α=.71).
Pittsburgh Sleep Quality Index (PSQI). The index consists of 19 items assessing respondents’
sleep quality over a one month interval. Seven components can be generated (subjective sleep quality,
sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication
and daytime dysfunction), each weighted equally on a 0-3 scale. Respondents received a score ranging
from 0 to 21, by summing the score for each subcomponent. A high score indicates more severe sleep
problems (Buysse, Reynolds, & Monk, 1989) (α=.61).
The Use of Media as a Sleep Aid in Adults
6
Sleep Duration. Sleep duration is one of the seven components of the PSQI. Sleep duration was
assessed by asking respondents how many hours of sleep they got on average per night during the past
month.
Fatigue Assessment Scale (FAS). This self-report fatigue scale comprises 10 items indicating
symptoms of fatigue, where respondents assess how they usually feel using a 5-point scale. The scale
has demonstrated good reliability and validity (Michielsen & Vries, 2004). A principal component
factor analysis indicated that these items loaded on one factor (eigenvalue = 4.14, explained variance =
41.4%). The total score ranges from 0 to 50, and a higher score indicates more severe symptoms of
fatigue (α = .83).
Bedtime & rise time. Respondents were asked to indicate what time they usually went to bed at
night and got up in the morning. For the purpose of the analyses, minutes were divided by 60 and
multiplied by 100. To obtain a metric variable, hours were counted from 0 to 24, and hours after
midnight were counted as 25 (for 1:00), 26 (for 2:00), etc..
Confounding variables. We entered gender (0 = male, 1 = female), age, and educational level
as control variables. Respondents who indicated they were students (N= 77) were excluded from
analyses in which level of education was used.
Analyses
Data were analyzed using statistical package SPSS for Windows (Version 22.0, Chicago, IL, USA).
Bivariate statistics (t tests, Pearson’s and Spearman correlations) were computed for the variables of
interest. Somers’ d was computed as a measure of ordinal association and univariate analyses of
variance were conducted to examine the main effects of the use different media as sleep aids on the
sleep variables. Binomial logistic regression analysis was used to investigate the relationship between
(1) the presence of media in the bedroom and the use of media as sleep aids and (2) the use of media as
sleep aids and the PSQI-score.
The Use of Media as a Sleep Aid in Adults
7
Results
A total of 2130 addresses were visited, of which 173 (8%) were not usable. Non-usable
addresses included addresses where the interviewer reported feeling unsafe, addresses that were no
longer occupied, for sale or non-residential or where the selected respondent did not speak Dutch.
Contact was made with 1957 addresses, of which 687 (32%) refused participation, 426 (20%) did not
answer the door on three separate visits. Response rate was therefore 43%. Data were carefully
examined for coding errors and other abnormalities such as outliers, true impossible values and missing
values. A total of 844 questionnaires were retained for analysis. The sample consisted of 56% women.
Respondents were between 18 and 94 years old, with an average of 46.0 years (SD = 17.8). About one
in five (20.7%) of the respondents had at least obtained a university degree, 31.8% had received a
college degree, 29.9% had a degree of secondary school and 5.7% had received a degree of primary
school. Almost one in ten respondents (9.2%) were still studying and 2.6% had no degree.
Media use as a sleep aid
Table 1 shows the prevalence of the use of media as a sleep aid. One in ten respondents (10.8%)
indicated they often used television as an aid to fall asleep, 12.0% used it sometimes and 8.4% rarely.
There were no differences according to gender or level of education, but respondents who indicated
they had a television in the bedroom used television significantly more often as a sleep aid (Somers’ d:
.390, p<.0001): 21.8% of respondents with a television in the bedroom used it sometimes as a sleep aid,
compared to 8.2% of respondents without a television in the bedroom. One in four respondents who
had a television in the bedroom used it regularly as a sleep aid (24.8%), compared to 5.4% of
respondents without a television in the bedroom. The odds of using television as a sleep aid were six
times higher for those who had a television in the bedroom than for those who did not (OR = 6.34,
p<.0001) (see Table 2).
For videogames, 10.3% indicated they used them at least occasionally as a sleep aid. Men used
videogames significantly more often to help them fall asleep than women did (Somers’ d: -.099,
p=.002): 14% of men indicated using videogames as a sleep aid, compared to 7.2% of women. Use of
The Use of Media as a Sleep Aid in Adults
8
videogames as a sleep aid was not related to educational level. Respondents who had a game console
in the bedroom reported using videogames as a sleep aid more often that those who did not (Somer’s d
= .303, p<.0001): 21.2% of the respondents who had one indicated using it as a means to fall asleep
occasionally, and 21.2% used it regularly. For respondents who did not have a game console in the
bedroom, 2.4% and 2.0%, respectively, used them as a sleep aid. More specifically, the odds of using
videogames as a sleep aid were 10 times higher for respondents who had a game console in the bedroom
(OR = 10.29, p<.0001) (see Table 2).
One in four respondents (26.0%) reported using music to help them fall asleep. Ten percent
(10.7%) did this sometimes. There was no significant difference according to gender. For educational
level, we found a small but significant positive correlation (r = .09, p=.009): the higher the educational
level, the more they reported using music as a sleep aid. Respondents who had a computer or
smartphone in the bedroom were 3.13 times more likely (p<.0001) and 1.88 times more likely (p=.004),
respectively, to use music as a sleep aid (see Table 2).
Almost 40% of the sample reported using books as a sleep aid. One in five respondents (19.1%)
reported doing this sometimes. There was a significant difference according to gender (Somers’ d: .182,
p<.0001): 21.7% of women and 15.9% of men reported using books as a sleep aid occasionally; 13.8%
of women and only 4.1% of men reported regularly using books as a sleep aid. Using books as a sleep
aid was significantly related to educational level: higher educated respondents reported using books
more frequently than less educated respondents (r = .197, p<.0001).
Finally, almost a fourth of the respondents (23.2%) reported using the internet to help them fall
asleep. There was no significant difference by gender, but using the internet as a sleep aid was
significantly related to educational level (r = .177, p<.0001). Highly educated respondents used the
internet more frequently as a sleep aid than less educated respondents. Respondents who reported
having a computer, smartphone or tablet computer in the bedroom used the internet significantly more
often as a sleep aid than those who did not (Somers’ d: .491, p<.0001; .348, p<.0001; .235, p<.0001).
More specifically, respondents who had a computer, tablet computer or smartphone in their bedroom
The Use of Media as a Sleep Aid in Adults
9
were 3.98 (p<.0001), 2.75 (p<.0001) and 2.92 (p<.0001) times, respectively, more likely to use the
internet as a sleep aid (see Table 2 for Odds Ratios and 95% Confidence Intervals).
[INSERT TABLE 1 ABOUT HERE]
[INSERT TABLE 2 ABOUT HERE]
Age
The use of media as a sleep aid was significantly related to age: older respondents were less
likely to report using media as sleep aid (see Table 3). In comparison with the oldest (>55 years old)
age group, the middle age group (35-55 years old) was 2.8 times (OR =2.762, p<.0001) more likely to
use television as a sleep aid, 2.3 times more likely to use music as a sleep aid (OR = 2.289, p=.001),
2.4 times more likely to use the internet as a sleep aid (OR = 2.385, p=.005) and 1.4 times more likely
to use books as a sleep aid (OR = 1.420, p = .066). For the youngest age group (<35 years old) the odds
of using television as a sleep aid were 4.1 times higher (OR = 4.107, p<.0001) in comparison with the
oldest age group. For using videogames, music and the internet and books as a sleep aid, these odds
were, respectively, 15.7 (p<.0001), 5.5 (p<.0001), 13.7 (p<.0001) and 1.8 (p=.006) times higher
compared to the oldest age group (see Table 3).
[INSERT TABLE 3 AROUND HERE]
Sleep quality
Using media as a sleep aid was significantly related to the PSQI score. Figure 1 depicts the
relationship between the use of media as a sleep aid and the PSQI score, while controlling for gender,
age and educational level. In particular, the odds of having a PSQI score over 5, which indicates poor
overall sleep quality, was 47% higher for those who used television as a sleep aid at least occasionally
(OR = 1.47, p=.04) and 79% higher for respondents who used music as a sleep aid at least occasionally
(OR = 1.79, p=.013). Attributable risk is a calculation of the difference in incidence between exposed
The Use of Media as a Sleep Aid in Adults
10
and non-exposed groups and reflects the proportion of incidence (in our case, poor sleep quality)
attributable to the exposure (in our case, the use of media as a sleep aid) in relation to all cases (Webb,
Bain & Pirozzo, 2006). In the group of respondents who use television or music as a sleep aid at least
occasionally, 20.6% and 25.6% of the incidence of poor sleep quality could be attributed to their use of
these media as sleep aids, respectively.
None of the five media types were significantly related to sleep duration. Sleep hygiene was
significantly related to the use of all media as a sleep aid: television (r =.271, p=.000), videogames (r
=.236, p<.0001), music (r = .277, p<.0001), books (r=.151, p<.0001) and internet (r =.416, p<.0001).
People who reported using media as a sleep aid scored significantly higher (worse) on the sleep hygiene
index.
Bedtime and rise time
There were significant correlations between the use of media as a sleep aid and the time at
which respondents reported going to bed. Using videogames (r = .180, p<.0001), music (r = .131,
p<.0001) or the internet (r = .234, p<.0001) as a sleep aid were positively related to later bedtimes.
However, they were also related to later rise times: videogames (r = .221, p<.0001), music (r =.154,
p<.0001), internet (r =.236, p<.0001). Figures 2 and 3 show the relationship between the use of media
as a sleep aid and bedtime and rise time respectively, while controlling for gender, age and educational
level.
Fatigue
Using media as a sleep aid was significantly related to a higher score on the Fatigue Assessment
Scale. Respondents who reported higher use of television (r = .115, p=.001), videogames (r=.130,
p<.0001), music (r = .146, p<.0001) or the internet (r = .142, p<.0001) as a sleep aid, also reported
higher fatigue. The relationship between the use of media as a sleep aid and fatigue, while controlling
for gender, age and educational level is shown in Figure 4.
[INSERT FIGURE 1 – 4 ABOUT HERE]
The Use of Media as a Sleep Aid in Adults
11
Discussion
The present study examined the use of media as a sleep aid in adults and its association with
sleep quality. Three observations can be made based on the current findings. First, the use of media as
a sleep aid appears to be a prevalent practice among adults: almost 40% used books, 31% used
television, 26% used music, 23% used the internet and 10% used videogames. However, the frequencies
of the use of media as a sleep aid by adults appear to be lower than those reported for adolescents
(Eggermont & Van den Bulck, 2006) and our results indicated that a negative relationship exists with
age. It thus seems that as age increases, the use of media as a sleep aid decreases.
Second, the presence of media in the bedroom facilitates their use as a sleep aid. The odds of
using television, videogames or the internet as a sleep aid were substantially higher for respondents who
indicated having a television set, computer, game console or smartphone in their bedroom. This
suggests that reducing the presence of media in the bedroom offers interesting avenues for intervention.
Third, using media as a sleep aid does not seem beneficial for sleep quality. Results indicated
that using television, music, books, and videogames as a sleep aid was related to a higher PSQI score,
thus indicating worse overall sleep quality. It was also linked to higher fatigue scores, supporting the
hypothesis that media use before bedtime is not indicative or supportive of healthy sleep behavior,
corroborating previous findings by Eggermont & Van den Bulck (2006) in adolescents. However, none
of the media were related to sleep duration, suggesting no impact on hours of sleep obtained by adults
and hence no sleep displacement. This confirms earlier findings regarding media use and adult sleep by
Custers & Van den Bulck (2012). In comparison with Eggermont & Van den Bulck (2006), whose
results indicated that using media as a sleep aid was negatively related to the number of hours of sleep,
our findings do not support such a conclusion for adults. The Time Shifting hypothesis (Custers & Van
den Bulck, 2012; Van den Bulck, 2004) may explain this discrepancy. In our sample, the use of
videogames, music and the internet as a sleep aid was related to later bedtimes, but also to later rise
times. Such compensatory behavior, where later bedtimes coincide with getting up later is less evident
for adolescents, whose time schedule is determined strongly by school hours and parents. Therefore,
The Use of Media as a Sleep Aid in Adults
12
their media use is more likely to displace sleep time, resulting in more tiredness during the day and
shorter sleep duration.
In conclusion, based on our data and those of Eggermont & Van den Bulck (2006), various
media are being used as a self-treatment strategy for sleep difficulties by a considerable proportion of
adolescents and adults on a fairly regular basis. It appears that such media use is harming their sleep,
rather than improving it. These findings are nonetheless based on cross-sectional, self-reported data.
The next step for future research would be to determine causality. It remains possible that adults who
use media as a sleep aid, while generally more tired than adults who do not use media, might be even
more tired if they did not use media as a sleep aid, as was suggested by Eggermont & Van den Bulck
(2006). In the absence of longitudinal data to determine the causal direction of the relationship, such an
explanation remains hypothetical and no certain advice can be given about media as a sleep aid, either
as a facilitator or inhibitor. Given that our sample was not recruited based on their sleep complaints, an
interesting suggestion for future research would be to compare the use of media as a sleep aid in a case
control study of individuals with and without (clinically diagnosed) sleep complaints. Also, questions
are left unanswered as to what constitutes the use of media as a sleep aid. While the studies to date have
used a single question measure that is certainly useful for exploratory studies, is has left the definition
of media use as a sleep aid open for interpretation. Future studies may thus benefit from delineating
clearly what is to be understood by media use as a sleep aid, or multiple item scales could be used to
probe the gratification sought by media use before bedtime to differentiate between adults who use
media as a sleep aid and adults who do not.
Finally, researchers studying the relationship between media use and sleep have to be extremely
sensitive to the rapid changes in the media landscape. It is fair to wonder to what extent respondents in
our study experienced a blurring of the lines between types of media use. With the advent of tablet
computers and smartphones, media content and media hardware are no longer synonymous. People can
watch television, play a game or read a book on their smartphone in bed. By the time this paper is
published, further developments may have occurred. Soon, answering the question “do you watch
television in the bedroom”, “do you read a book” and even “do you play a computer game” may be
The Use of Media as a Sleep Aid in Adults
13
confusing to people who have become unsure whether exposing themselves to such media
entertainment on, say, a tablet computer qualifies as such media use.
The Use of Media as a Sleep Aid in Adults
14
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